Provider Demographics
NPI:1427334721
Name:A SECOND CHANCE
Entity type:Organization
Organization Name:A SECOND CHANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VAHE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAKIMIAN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMIN/PHARMACY TECH
Authorized Official - Phone:626-430-6197
Mailing Address - Street 1:707 N FOXDALE AVE
Mailing Address - Street 2:714 N. SUNSET AVE
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1213
Mailing Address - Country:US
Mailing Address - Phone:626-430-6197
Mailing Address - Fax:626-430-7404
Practice Address - Street 1:707 N FOXDALE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1213
Practice Address - Country:US
Practice Address - Phone:626-430-6197
Practice Address - Fax:626-430-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABBS4936251K00000X
CA162257251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherSINGLE SPECIALITY GROUP
CA390200000XOtherSTUDENT IN AN ORGANIZED HEALTH CARE EDUCATION TRAINING PROGRAM
CA261Q00000XOtherCOMMUNITY CLINIC CENTER
CABBS4936OtherAGENCY
CAAGENCYOtherVICITMS OF CRIME